chapter  Chapter 10
Record-keeping
WithBarbara Smith, Linda Field
Pages 27

This chapter considers aspects of record-keeping, including the purpose of keeping records, the legal aspects, the types of nursing documentation available, and the use of information technology and electronic records. It shows an awareness of the purpose of keeping records and discusses the legal aspects of record-keeping in relation to the Nursing and Midwifery Council (NMC). The chapter provides an understanding of the importance of accountability and confidentiality when keeping records and outlines the various forms of nursing documentation. It presents the emergence of electronic records and the impact of information technology in healthcare. The chapter proposes an understanding of the standards for record-keeping and the essential elements set out by the NMC and explains what is meant by regulation and outline the Code of Professional Conduct. It also considers several aspects of good record-keeping, including the purpose of keeping records and nursing documentation and the standards set by the NMC to help ensure all records are legible, accurate and chronological.